Archive for the ‘Babesia’ Category

Babesia Microti Imported Into Foreign Countries

https://danielcameronmd.com/babesia-microti-imported-foreign-countries/

BABESIA MICROTI IMPORTED INTO FOREIGN COUNTRIES

Man with babesia microti infection travelling with suitcase

Over the past two decades, there have been reports of the tick-borne infection Babesia microti being imported into foreign countries from the United States. International travelers are unknowingly carrying the disease into countries, which may be unfamiliar with diagnosing tick-borne illnesses.

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“Recently, sporadic cases of human babesiosis caused by several species of Babesia have been reported in other countries,” write the authors of “Imported Human Babesiosis, Singapore, 2018.” [1] These cases include:

  • Babesia microti (Germany, Australia, South Korea)
  • Babesia microti-like (Japan, Taiwan, China)
  • Babesia duncani (United States, Canada)
  • Babesia divergens (Europe)
  • Babesia venatorum (Europe, China)
  • Babesia crassa-like (China)
  • Babesia motasi-like (South Korea)

Additionally, in 2003, Nohýnková and colleagues reported what was believed to be the first case of symptomatic Babesia microti infection imported into the Czech Republic from the United States. [2] Meanwhile in 2013, investigators described the “first human case of Babesia microti infection imported to Denmark from the United States by a 64-year-old female traveler with fever of unknown origin.” [3]

READ MORE: Tourists visiting the United States contract Babesia, leaving one dead

According to the authors, “The case raises the possibility that Babesia infections may be under-diagnosed, [and] illustrates the importance of a thorough travel history…” [3]

The number of international travelers carrying tick-borne diseases into foreign countries is rising, making it increasingly important for clinicians to gather a thorough travel history on patients. CLICK TO TWEET 

Two recent case reports demonstrate the rise of tick-borne diseases being imported into other countries and highlights the challenges clinicians face in distinguishing these illnesses, specifically Babesia microti, from malaria.

Case 1: Singapore

A 37-year-old man traveled to multiple places in the year before his illness. His travel history included Vietnam, Thailand, Indonesia, Cambodia, Indonesia, and the United States.

On June 17, 2018, after visiting the Northeastern USA, he noted a right ankle papule that lasted 3 weeks. “He sought consultation at a travel clinic [in Singapore] because of high fever (104°F), rigors, and headaches, which had persisted and worsened over 18 days,” writes Lim and colleagues. [1]

Doctors had prescribed amoxicillin, but the symptoms persisted.

LISTEN TO PODCAST: Babesia treatment of two travelers

“Laboratory test results revealed moderate thrombocytopenia and anemia, and malaria blood films revealed trophozoites forming in erythrocytes, suggestive of Babesia,” writes Lin.

The doctors confirmed the diagnosis of Babesia microti with additional testing. He was treated successfully with quinine and clindamycin.

Case 2: Spain

“A 72-year-old man with a 15-day history of fever, generalized arthralgia, asthenia, and decreased appetite was admitted to Hospital Universitario San Cecilio, Granada, Spain,” writes Guirao-Arrabal and colleagues in “Imported babesiosis caused by Babesia microti − A case report.” [4]

The man had a history of sweating and his inflammatory markers were elevated. He also had a history of type 2 diabetes.

He reportedly traveled to a park in Westchester County, NY, an area that is considered endemic for babesiosis.

Malaria was considered based on intraerythrocytic forms in the red cells. The malaria antigen and PCR tests for malaria were negative.

Babesia microti was presumed with a low level of parasitemia (0.5 %). There was no evidence of another tick-borne illness. After treatment with atovaquone and azithromycin, his parasitemia resolved.

Editor’s note: It is encouraging to see that Babesia is now being considered by clinicians and treated appropriately.

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For more:  https://madisonarealymesupportgroup.com/category/babesia-treatment/

 

Category:

Babesia, research

Babesia Infection 3 Weeks After Lyme Treatment

https://danielcameronmd.com/lyme-podcast-a-babesia-infection-3-weeks-after-treatment-for-lyme-disease/

LYME PODCAST: A BABESIA INFECTION 3 WEEKS AFTER TREATMENT FOR LYME DISEASE.

A Babesia infection 3 weeks after treatment for Lyme disease.

I will discuss a 67-year-old woman with a Babesia infection 3 weeks after treatment for Lyme disease. Could this delay explain why some patients remain ill or relapse?

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Podcast:

https://podcasts.google.com/feed/aHR0cHM6Ly9mZWVkcy5idXp6c3Byb3V0LmNvbS83NzI

Hoversten and her colleague first discussed this case in the British Medical Journal Case Reports  in 2018.

One would expect that tick-borne infections would all occur at the same time.

One would be wrong, as this case illustrates.

A 67-year-old woman from Wisconsin had extensive exposure as an avid gardener and spent a considerable amount of time outdoors.

She did not see a tick. She did see a rash consistent with an erythema migrans rash.

A delay in onset of Babesia may explain why some Lyme disease patients relapse after initially improving with doxycycline or amoxicillin. CLICK TO TWEET

She was prescribed amoxicillin for three-weeks as she was allergic to doxycycline.

Near the end of three-week of amoxicillin, she became ill. Her fever rose to 102.9 F0. She complained of myalgias, dizziness, and fatigue.

Her blood test showed mild anemia, a low platelet count and neutrophil count, and a very high C-reactive protein.

  • neutrophil is a type of white blood cell that helps resolve infections and heal damaged tissues. A low neutrophil count can be seen in tick-borne diseases.
  • A high C-reactive protein is a marker for inflammation but cannot be used to determine what type of inflammation.

She was admitted to the hospital. The doctors thought she might be suffering from sepsis or a tick-borne infection.

  • Sepsis is a life-threatening illness caused by your body’s response to an infection.
  • Her red blood count and platelets continued to drop.
  • She was transferred to a second hospital.
  • There was no evidence of sepsis. The blood cultures were negative after five days.

BABESIA INFECTION

She was diagnosed with the parasite Babesia microti by PCR and by a thin smear of her red blood cells. Typically, Babesia microti is seen on a thick smear of blood. In her case, 0.4% of her red blood cells showed the parasite Babesia microti on a thin smear.

Babesia infections can be severe and, in rare cases, life-threatening. Babesia infections can also be mild or without symptoms. Babesia was more likely to be severe in this woman as she was over 50-years of age and had a history of colon cancer.

She was prescribed a 10-day course of azithromycin and atovaquone. By 5th day of treatment, her fever had resolved, and her platelet count had more than doubled from a low of 17,000 per dl to 42, 000 per dl.

The authors report that the woman remains fatigued after completing treatment.

The authors discussed the nearly three-week gap in time between the woman’s erythema migrans rash and her diagnosis of Babesia. This is not the first case where the onset of Babesia was delayed.

The authors cited two papers describing a 3 to 4-week delay in the onset of Babesia. I described a paper in an earlier podcast where two babies contracted Babesia from their mothers. They did not present with Babesia until after being discharged from the hospital. You can read more about these babies in the article by Saetre and colleagues or listen to my Inside Lyme podcast titled. “Two children who contacted Babesia from their mother.”

This delay may explain why some Lyme disease patients relapse after initially improving with doxycycline or amoxicillin. Treatment for Lyme disease with doxycycline or amoxicillin is not effective for the treatment of Babesia.

What can we learn from this cases?

  1. Babesia infections can occur weeks after the onset of Lyme disease.

What questions does these cases raise?

  1. Should the woman have been evaluated for Babesia infection at the time of the erythema migrans?
  2. Would a Babesia infection have been recognized if the woman had not been diagnosed with Lyme disease?
  3. Should Lyme disease patients be advised to return for follow-up?
  4. Would earlier treatment have avoided the need for hospitalization?
  5. What is the long-term outcome for this woman with a Babesia infection

TREATING TICK-BORNE DISEASE IN MY PRACTICE

In my practice, each individual requires a careful assessment. That is why I order a broad range of blood tests for other illnesses in addition to tick-borne infections. I also arrange consultations with specialists as needed.

Many patients are complex, as highlighted in this Inside Lyme Podcast series.

We need more doctors with skills recognizing Babesia in a patient with Lyme disease. We hope that professionals evaluating individuals with Lyme disease can use this case to remind them to look for Babesia with Lyme disease.

Inside Lyme Podcast Series

This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube.  As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts.

Sign up for our newsletter to keep up with our cases.

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For more:  

Category:

Babesia, Lyme, research, Treatment

Babesia Infections Explode In Hudson Valley, NY

https://danielcameronmd.com/babesia-infections-explode-in-hudson-valley-region/

BABESIA INFECTIONS EXPLODE IN HUDSON VALLEY, NY

man sick with babesia infection

Babesia, a parasitic infection usually transmitted through a tick bite, was once thought to be a coastal tick-borne disease limited to Suffolk County on Long Island. Some doctors had been reluctant to acknowledge that Babesia could be found in other locations. But in 2001, Babesia infections were reported in lower Hudson Valley, New York, a region north of Manhattan and has since continued to spread with an increase in the number of cases far beyond the borders of Long Island.

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In their article “Increasing incidence and changing epidemiology of babesiosis in the Hudson Valley region of New York State: 2009-2016,” ¹ Joseph and colleagues question how cases of Babesia infections are spreading given that the animal reservoirs mice, shrews, and voles typically do not travel large distances.
Cases of Babesia have been reported in two counties located east of the Hudson River: Dutchess County and Westchester County, the authors write. (Westchester County alone has a population of nearly 1 million residents.)

Read More: Babesia remains a clinical diagnosis for some patients.

But since 2009, there has been an explosion of Babesia infections in the Upper Hudson Valley, New York region. This area consists of Albany County, Columbia County, Greene County, and Rensselaer County.

Over an 8-year period (between 2009-2016), there was a 16.8-fold increase in the incidence of Babesia cases in the Upper Hudson Valley region.

The number of Babesia cases explodes in the upper Hudson Valley, NY region. CLICK TO TWEET

The number of cases also increased in the Lower Hudson Valley region, which consists of Dutchess County, Putnam County, Westchester County, Orange County, Rockland County, Sullivan County, and Ulster County.

The actual number of Babesia cases is likely higher:

  1. It was not until 2011, that the Centers for Disease Control and Prevention (CDC) made Babesia a reportable disease. Between 2011 and 2016, New York State had a reported 2,750 cases of Babesia, the highest number in any state in the U.S.
  2. Babesia can be difficult to identify since the parasites in the red blood cells can quickly clear.
  3. Lastly, Babesia cases may not be recorded if the physician does not report the case to the CDC.

“In conclusion, babesiosis is a rapidly emerging infection in the Hudson Valley region of New York State, the geographic region now accounting for more cases than any other single geographic area in the state,” the authors write.

Therefore, “clinicians caring for patients with symptoms compatible with babesiosis, who live in or have traveled to the Hudson Valley region of New York State, should consider the possibility of babesiosis.”

Editor’s Note: I have practiced medicine in the Hudson Valley, New York region for more than 33 years. I have treated patients with Babesia infections for the past three decades. Many of the first patients first described with Babesia were caught early when Babesia microti was seen in the red blood cells. I typically diagnose cases of Babesia with a positive antibody test or using clinical judgment.

In addition, the authors addressed Babesia microti in their paper. I have seen evidence that Babesia duncani appears to be a problem in the area. Babesia duncani was first identified on the West Coast. We need more research on this tick-borne disease.

Lastly, the presence of Babesia has important treatment considerations. Neither doxycycline nor amoxicillin are effective in treating Babesia. Patients with Lyme disease, co-infected with Babesia, would need a combination of antimicrobials to include an anti-parasitic medication (i.e., azithromycin combined with Atovaquone).

Related Articles:

Severe Babesia infection leads to exchange transfusion

Case series looks at the complexity of Babesia

Podcast: Two children who contracted Babesia from their mothers

References:
  1. Joseph JT, John M, Visintainer P, Wormser GP. Increasing incidence and changing epidemiology of babesiosis in the Hudson Valley region of New York State: 2009-2016. Diagn Microbiol Infect Dis. 2020 Feb;96(2):114958.

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**Comment**

If doctors aren’t reporting it (and it wasn’t even a reportable illness until 2011) the CDC isn’t counting it.  

For more:  https://madisonarealymesupportgroup.com/2016/01/16/babesia-treatment/

https://madisonarealymesupportgroup.com/2020/02/09/severe-babesia-infection-leads-to-exchange-transfusion/

https://madisonarealymesupportgroup.com/2019/09/05/babesia-subverts-adaptive-immunity-and-enhances-lyme-disease-severity/

https://madisonarealymesupportgroup.com/2018/10/11/babesia-found-in-patient-with-persistent-symptoms-following-lyme-treatment/

https://madisonarealymesupportgroup.com/2018/03/22/what-is-air-hunger-anyway/

https://madisonarealymesupportgroup.com/2018/05/31/widespread-babesiosis-in-canada/

https://madisonarealymesupportgroup.com/2017/11/07/congenital-babesiosis-in-two-infants/

Category:

Babesia, research, Treatment

Frequency & Magnitude of Seroreactivity to Babesia Microti in 245 Patients Diagnosed by PCR in N.Y. State

https://www.ncbi.nlm.nih.gov/pubmed/32113703

2020 Jan 29:115008. doi: 10.1016/j.diagmicrobio.2020.115008. [Epub ahead of print]

Frequency and magnitude of seroreactivity to Babesia microti in 245 patients diagnosed by PCR in New York State.

Madison-Antenucci S1, Wormser GP2, Levin AE3, Wong SJ4.

Abstract

Multiple methodologies have been used to detect antibodies to Babesia microti. Use of an indirect immunofluorescence assay (IFA) has been the most widely used approach, but IFAs have varied as to which antibody class or classes are being detected and in regard to cutoff titers. In this study, 245 different patients with polymerase chain reaction (PCR)-confirmed B. microti infection were tested by a polyvalent IFA using serum collected within 3 days of the date the blood sample for PCR testing was obtained. Of the 245 patients, 243 (99.2%) had a positive serologic test result (i.e., ≥1:64). Of the 243 patients who were seropositive, 242 (99.6%) had a titer of ≥1:256, 236 (97.1%) had a titer of ≥1:512, and 210 (86.4%) had a titer of ≥1:1024. In conclusion, high titer seropositivity based on a polyvalent IFA is to be expected at the time of PCR confirmation of active babesiosis in clinical practice.

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For more:  https://madisonarealymesupportgroup.com/2016/01/16/babesia-treatment/

Category:

Babesia, research, Testing

Lyme Podcast: 6-Week Old Boy With Babesia

https://danielcameronmd.com/lyme-disease-podcast-6-week-old-boy-babesia/  Go here for Podcast

LYME PODCAST: 6-WEEK-OLD BOY WITH BABESIA

Lyme Disease Podcast: 6-week-old boy with Babesia

Welcome to an Inside Lyme case study. I find that the best way to get to know Lyme disease is through reviewing actual cases. In this case study, I will be discussing a 6-week old baby boy with Babesia. This case series will be discussed on my Facebook and made available on podcast and YouTube.

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This case was described in the journal Pediatrics, written by Handel and colleagues in 2019.

The baby boy was seen in an emergency department in Long Island, New York, an area endemic for Lyme disease.  The baby spent “minimal time outside,” according to Handel.  There was tall grass in the yard and the father painted home exteriors. The parents did not report seeing a tick. Instead, the parents removed a bloody “flea” from his arm 20 days before hospitalization writes Handel

This highlights the difficulties parents can face in recognizing a tick.

The baby boy was irritable, throwing up, not eating well, and had a temperature of 101.1°F. The doctors were initially not able to identify the reason the baby boy was ill or why there was anemia or a low platelet count. The doctors prescribed three antibiotics – ampicillin, ceftriaxone, and vancomycin until they could determine a cause of the illness.

The baby boy was transferred to a second hospital. The blood tests again showed anemia and a low platelet count along with abnormal liver function tests. The spleen appeared large. The laboratory tests now revealed the parasite Babesia in the red blood cells under the microscope.  3.6% of the baby’s red cells showed parasites seen with Babesia.

Babesia is a parasitic disease that is typically contracted by the same tick that carries Lyme disease.  Babesia can also be contracted through the blood supply or during pregnancy.

The baby was prescribed oral atovaquone and intravenous azithromycin.  These drugs are marketed as Mepron and Zithromax in the US. The anemia worsened. The hemoglobin dropped to 6.9 gram/dl, which is quite low. The doctors transfused a unit of blood. The doctors were concerned that the baby might also have suffered from Lyme disease. The doctors added 14 days of amoxicillin to the treatment.

The baby remained well on follow-up, according to the doctors.

What can we learn from this case?

  1. This paper reminds parents of the need to look for tick bites even in babies.
  2. Babies can be infected with a tick-borne infection even with little outdoor exposure.
  3. It can be difficult to determine if a baby has Babesia.  The baby was not diagnosed with Babesia until transferred to a second hospital and then only because parasites were seen in the blood.
  4. It can be difficult to be sure a baby does not suffer from Lyme disease.  In this case, the doctors elected to treat the baby with amoxicillin in case there was a co-infection.  I might have continued azithromycin rather than add amoxicillin, as azithromycin has also been effective in Lyme disease.

What questions does this case raise?

  1. Would it have been helpful if the parents had recognized the “the bloody flea” as a tick?
  2. Would the doctor have recognized Babesia if the parasite were not seen in the red cells under the microscope?
  3. What if the baby girl had evidence of Ehrlichia or Anaplasmosis?  If so, the doctors would have to consider doxycycline.  Doctors have been reluctant to prescribe doxycycline in young children as the medication may discolor the teeth.  The age of which doctors are uncomfortable prescribing doxycycline has dropped to eight. Moreover, the CDC had notified doctors that two weeks of doxycycline is safe in all children up for up to two weeks. I am sure we have not heard the last of this discussion.
  4. What is the best combination of treatment and length of treatment to prevent long-term complications in children?
  5. How do you know a baby is well when they cannot communicate how they are feeling?  We only know that the parasite Babesia is no longer visible under the microscope.

TREATING TICK-BORNE DISEASE IN MY PRACTICE

In my practice, each individual requires a careful assessment. That is why I order tests a broad range of tests, including blood counts, liver and kidney function, thyroid disease, lupus, and rheumatoid arthritis, in addition to tests for tick-borne infections. I also arrange consultations such as neurologists, rheumatologists, and ophthalmologists.

Many patients are complex, as highlighted in this Inside Lyme Podcast series.

We need more doctors with skills diagnosing and treating Babesia in children. We could use a reliable test to determine who has Babesia and a test to be sure Babesia  has resolved. We need to determine the best course of treatment for babies. We hope that if a professional sees a baby that they can use this case to remind them to look for Babesia and treat accordingly.

We also need to give doctors the freedom to treat these difficult cases without undue interference by colleagues, insurance companies, medical societies, and medical boards.
Inside Lyme Podcast Series

This Inside Lyme case series will be discussed on my Facebook and made available on podcast and YouTube.  As always, it is your likes, comments, and shares that help spread the word about this series and our work. If you can, please leave a review on iTunes or wherever else you get your podcasts.

Sign up for our newsletter to keep up with our cases.

References:
  1. Two Neonates With Postnatally Acquired Tickborne Infections Andrew S. Handel, Harriet Hellman and Saul R. Hymes Pediatrics 2019;144;

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For more:  https://madisonarealymesupportgroup.com/2016/01/16/babesia-treatment/

Category:

Babesia, Treatment